| Daily Briefing

These 8 clinical innovations are coming soon (and could transform health care)

It's almost impossible to keep up with the constant wave of new technological and clinical advancements touted every day in health care without feeling utterly overwhelmed. Advisory Board experts are here to help. They outline the eight clinical innovations and advancements that you should know about today—and predict the impact they could have on the future of health care.

Innovation 101: Cheat sheets for today's digital world

1. Organoids: The exciting innovation in personalizing treatment plans... that sounds like an eighth grade science experiment gone wrong

By Deirdre Saulet, Ph.D., Practice Manager, Oncology Roundtable

We live in an age characterized by rapid advances in genomic testing and precision medicine. But given how early we are in our journey towards precision medicine, there's a finite limit as to how much a tumor's DNA can tell us about the right—or wrong—treatment. Introducing: Organoids. 

You can probably guess what they are from the descriptive (and slightly gross-sounding) name: Three-dimensional tumor cell cultures that can be grown in a lab and mimic what is happening inside the body. Researchers have developed organoids for breast, prostate, liver, pancreatic, and brain tumors. The bet is that organoids derived from a patient's tumor can be used to test multiple drugs and reveal which drug the tumor will respond to best. In fact, a Science study last year found that organoids predicted when drugs wouldn't work in patients 100% of the time and when drug would work 90% of the time. 

Researchers are thrilled about the unique potential of organoids in screening a large number of treatments quickly to deliver personalized treatment. In fact, if you enter the term "organoids" into PubMed, you'll see 722 results from this year so far (compare that to 744 in all of 2018 and 559 in 2017). I personally can't wait for all of this exploration to become a reality (but can we come up with a sexier name?)

2. Next-generation mobile health: Why we may finally be ready to shift care outside of the hospital

By Aaron Mauck, Ph.D., Senior Director, Research

Mobile health is hardly a new concept, but most applications available have been long on promises and short on results. That is starting to change. In the race to develop disease management technologies that can reliably reduce costs while improving long-term outcomes, mobile health (or mHealth as it is often called) may prove essential.

Many within healthcare have been understandably bearish on mHealth: Existing platforms often rely on a combination of education and nudges to alter health behaviors, and operate in a similar way to the video games we play on our phones. While this approach keeps people engaged, it is unclear whether it can lead to permanent behavioral changes or improve health outcomes. Emerging platforms take a different approach, often employing a mobile health interface alongside remote monitoring technologies (such as a wearable or implantable device), coupled with additional data functionality that allows the platform to track patient outcomes and tailor interventions to unique patient needs. In this approach, mHealth is one link in a longer chain, driven by data, providing a real-time response to the changing care needs of the patient.

Not all patients are likely to benefit significantly from such platforms, and careful patient selection will be essential to ensure its cost-effectiveness. But for patients living with chronic conditions that require continuous monitoring of biological data— conditions such as diabetes, cardiac rhythm management heart failure— mHealth may allow us to provide more and better care outside the hospital setting.

There are still sizeable challenges to overcome before we see mHealth adoption become widespread. One challenge simply involves proof of its effectiveness. In the case of diabetes, for instance, the Agency on Healthcare Research and Quality (AHRQ) has found that of the hundreds of apps available to patients, only a small percentage have published data in support of their claims. That has to change. Privacy and security concerns also abound, and are unlikely to be fully resolved in the near future. Most platforms need mountains of patient data on which to "learn" how to manage disease better, and it is as yet unclear how to ensure access to such data without compromising privacy. In addition, to reach their full potential, mHealth platforms must seamlessly interface with the IT infrastructure of existing health systems—a daunting task, given the IT challenges many systems still confront.

None of these challenges is insurmountable. With the advent of 5G connectivity, our ability to transmit and manage large amounts of data will improve considerably. The growing popularity of wearable devices also opens the door to a wide array of new data points on which platforms can learn. Most importantly, there are strong financial incentives for finding mHealth solutions that are actually proven to work. Given the skyrocketing costs associated with chronic diseases like diabetes, finding a solution that can reduce costs through effective management in the home is essential. mHealth may prove a central part of that solution. 

3. Personalized prescribing: We can now use our genes to personalize the drugs we take (and their doses)

By Brandi Greenberg, Managing Director, Life Sciences

I am fascinated by the way different people metabolize different drugs. For instance, a "wonder drug" antibiotic for my son triggered, in me, the side effects you only read about in the fine print of the official label. Or how similarly-sized people may require very different doses of common drugs to yield similar effects. 

But I'm also frustrated by how little of that metabolic and pharmacogenetic information has made its way into diagnostic tools that can aid clinicians, pharmacists, and families in matching drugs to patient. Genetic advances in oncology have yielded powerful tests for biomarkers that can aid in treatment selection. But the average parent of an ADHD child still endures a "trial and error" process with five to seven different drugs before finding one that works well and has minimal (or tolerable) side effects. I've heard similar stories about patients' search for "best fit" antidepressants. 

Therefore, I was really excited to learn that Myriad Genetics' GeneSight® testing panel is now accepted by Kroger and other leading prescription plans. The diagnostic tool—which analyzes how your genes may affect your response to medications commonly prescribed to treat ADHD and certain mental health disorders—has been around for nearly a decade, but Myriad's 2016 acquisition of GeneSight's parent company has expanded payer coverage and clinician awareness. I've also recently learned of several other in-development diagnostic tools designed to use genetic insights to guide not only drug selection but also individualized dosing and administration. I applaud such scientific exploration into precision diagnostics that can help us get it right the first time—thereby reducing unnecessary anxiety, suffering, and costs associated with the avoidable side effects from mismatched drugs and dosages. 

4. Chatbots: Your newest employees with the best bedside manner yet

By Veena Lanka, MD, Research Partner

Despite being someone who prefers in person conversations to texts, I'm remarkably excited by the arrival of chatbots in health care. Meet Ginger, Florence, Woebot, Babylon, Grace, Viki, Molly and many more digital avatars that are here to help you—no appointment or co-pay necessary. Before you dismiss me as a tech-savvy millennial, let me admit I'm neither adept at technology (someone explain portrait mode to me) nor an early adopter of technology (still no Twitter or Instagram accounts). Yet somewhere along the way, I seamlessly switched over into the new technological world (I now ask my TV to play my videos, read the transcribed text of voicemails, and text my bank).

The infusion of smart technology and instant service in our homes, our phones, and our appliances has prepared every non-tech savvy individual to expect the same from their providers. As a result, the global chatbot market is expected to reach $498M in just 10 years. Health systems, startups and inventors are noticing their potential and beginning to deploy chat bots to their patients, employees and the general public. The applications are endless. Take for instance, Kaiser Permanente, which just invested in a behavioral health coaching and tele-psychiatry app Ginger, and will make it available to all Kaiser employees. Florence, a nurse-like chatbot will send patients medication reminders, track vitals such as weight and mood over time, provide medical information, and show users where the nearest health services are located. Patients can now speak to chatbot Sensely which can recognize their language and use speech recognition and artificial intelligence to cross-check symptoms against a large database to provide recommendations on managing care at home versus heading to the hospital. Grace, a chatbot developed by Providence St. Joseph, provides patients instant virtual symptom-triage, recommends a specific action such as a same-day appointment or home visit, then can schedule an appointment, call a rideshare vehicle, and notify their primary caregiver via text. In addition to providing superior customer service and immediate care to the patient, bots like this can also provide much needed operational scale to hospitals, direct appropriate site-of-care and reduce inappropriate utilization of the ED. If it all sounds too futuristic or impractical for actual day-to-day use, consider that Woebot, a mental health chatbot app created by Stanford, has 1.42K reviews and an impressive 4.7 stars. Patients are ready, so is the technology—it's now time for providers to embrace these digital 'employees' and deploy them against their most pressing patient access and experience needs.

5. Bioelectronics: The future frontier for treating chronic disease?

By Andrea Martin, Senior Consultant, Health Care Advisory Board

I've long been fascinated by the field of bioelectronics. Imagine a device no larger than a grain of rice that is implanted next to a certain nerve—offering an avenue to deliver a moderated amount of electrical stimulation to control cell or organ function. It's a remarkable pathway to affect downstream responses in the body, and to do so without many of the side effects that pharmaceuticals have.

The field is still fairly new, but the large flows of money flowing into it are indicative of its tremendous potential. Take a look into some of the research in the field and you see the prospective impact on almost every disease—Type 2 diabetes, asthma, hypertension, arthritis– the list goes on and on. As we know, these chronic conditions drive a huge portion of health spending today, and have massive impacts on Americans' quality of lives. A new procedure to impact these conditions would not only change the way health care is administered today, but change the way people live to have healthier and happier lives.

One company pursuing the technologies, Galvani Bioelectronics, offers a helpful example of where the field stands. The company—a joint venture between Verily and GlaskoSmithKline—was created in 2016 with a $700 million joint investment. While the company has been fairly quiet on their progress, they are reportedly building a "nerve atlas" to map how different nerves module body functions and aiming for a product to hit the market by the mid-2020s.

Obviously, these are big names willing to bet serious money on the potential of this technology. And while the technology requires serious research before it is ready for market, the success of similar approaches like vagus nerve stimulation and deep brain stimulation offer hope that they may find success.

6. Not doing a procedure: The latest breakthrough in cardiovascular care?

By Megan Tooley, Practice Manager, Cardiovascular Roundtable

In CV services, it's hard not to get swept up in the latest and greatest technological advancements. After every cardiovascular conference, you receive a wave of emails on the newest structural heart devices, evolving procedural techniques, and robots who can operate on the heart with unparalleled precision. 

But perhaps what I'm most excited about looking ahead in CV are those innovations that may actually avoid the need for a procedure altogether.

Fractional flow reserve-computed tomography (FFR-CT) is a great example of a clinical innovation that can actually prevent unnecessary CV procedures. This noninvasive technology can more accurately diagnose if a patient requires an intervention for blocked arteries, reducing the need for diagnostic cath or percutaneous coronary intervention (PCI) in many patients.

I've also been excited to see the growing interest and evidence surrounding virtual cardiac rehabilitation. For years, the CV community has tried to increase utilization of cardiac rehab following certain CV events, like cardiac surgery or heart failure, but patients often find it difficult to attend the multiple sessions necessary to achieve results. Now, there is growing evidence that providing cardiac rehab virtually from the patient’s home can still have impressive results in reducing repeat CV events and readmissions – likely with far greater adoption from patients.

Don't get me wrong, I am amazed every day by the advancements in CV procedures – which are becoming safer, more durable, and able to treat patients who, until now, had no options for care. But I'm also so glad we're looking beyond the procedure to prevent unnecessary surgeries and repeat cardiovascular events.

 Curious to learn more about the newest advancements in CV care? Join our 2019-2020 Cardiovascular Roundtable national meeting series where we'll evaluate investments like these and get you up-to-date on what you need to know about them.

7. CRISPR: Why an experiment in China upended my bet on the future of clinical technology

By Vidal Seegobin, Practice Manager, Global Forum for Health Care Innovators

I'm a huge science fiction fan so stories about clinical innovations always spark my imagination. CRISPR— a technology that allows us to "edit" DNA—is one of those technologies that feels so futuristic that I can't help but follow it with fascination.

But I'm also a researcher and know that flashy headlines rarely translate to frontline impact. So the November 2018 story about CRISPR-edited twins in China completely blew up my entire calculus on the progress of the technology.

I've always believed that CRISPR would be limited by risk tolerance. Computational capabilities and gene mapping, the science of CRISPR, will always continue at a brisk pace. And the laws, while now surprisingly nebulous, will eventually evolve. But what I banked on keeping the technology at bay was the simple fact that parents would never subject their to-be-born baby to the risk of using "gene scissors."

Nevertheless, two little girls were born in October 2018—their DNA edited as embryos to confer an immunity to HIV. Now, there are many questions remaining with this case. As the story unfolds, more questions emerge, and it's not entirely clear the parents were given the proper information to consent. But to me, the science has overcome the major hump. Humanity has engineered a baby at the genetic level. We can argue the pace and speed of the advancements here but I don't think we're going back.

Those science fiction stories are starting to take on new resonance.

8. Digital therapeutics: The time may finally be ripe for them to take off

By Colin Gelbaugh, Consultant, Pharmacy Executive Forum

Looking into the future, I'm most excited about digital therapeutics that bring together consumer-grade mobile hardware, artificial intelligence-powered software, and a reimagined care team to tackle the growing health needs (and economic costs of) the chronic disease population. Hardware is becoming cheaper, more portable, and more connected. Software is becoming more predictive, prescriptive, and user-friendly. And progressive health systems are developing programs to harness real-time data from patients to create personalized and adaptive care plans. Together, this is a formula for using digital tools in new ways to manage, monitor, and prevent escalations of disease.

The FDA has taken a surprisingly proactive stance towards digital health technologies, and both industry incumbents and non-traditional players are capitalizing on the opportunity. A few newer applications include continuous glucose monitors for diabetic patients and consumer device-equipped EKG sensors for patients at risk of heart failure. In July, one digital health company, Livongo, became the first digital health company since 2016 to go public. Some early reports indicate that its AI-enabled, connected glucose monitor is lowering costs by $88 per member per month and reducing mean A1c levels from 7.8% to 6.9%. As companies like Livongo grow and expand, and early adopters demonstrate improvements in outcomes, I'd expect both the costs of devices to go down and sustainable reimbursement models to take shape. The growing market with spur new applications for more health conditions, and providers will have a greater opportunity to harness digital therapeutics in mainstream care.






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